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General NPI Number Information
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NPI Number | 1245271642
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Entity Type | Individual
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Provider Name | DEANNE R GRIM PA
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Gender | Female
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Dates
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Enumeration Date | 06/09/2006
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Last Update Date | 12/21/2021
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Provider Practice Location Address
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Address Line | 4089 WEBSTER ROAD
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City | SUMMERSVILLE
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State | WV
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Zip | 26651
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Country | US
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Telephone | 304-872-0111
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Fax |
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Provider Business Mailing Address
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Address Line | 330 NELSON AVENUE
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City | SUMMERSVILLE
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State | WV
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Zip | 26651-1743
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Country | US
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Telephone | 304-619-1018
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 01180
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License Number State | WV
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